Two weeks after returning home from traveling, a client presents to the clinic with conjunctivitis and describes a recent loss in the ability to taste and smell. The nurse obtains a nasal swab to test for COVID-19. Which action is most important for the nurse to take?

For Potential Conditions:

The correct answer is c) Abdominal compartment syndrome.

Choice A reason: Pneumothorax is a condition where air leaks into the pleural space, causing lung collapse and impaired gas exchange. It can cause respiratory distress, hypoxia, chest pain, and decreased breath sounds on the affected side. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice B reason: Pulmonary embolism is a condition where a blood clot blocks one or more pulmonary arteries, causing impaired gas exchange and reduced blood flow to the lungs. It can cause respiratory distress, hypoxia, chest pain, and tachycardia. However, it does not cause abdominal distension, acidosis, or hyperglycemia.

Choice C reason: Abdominal compartment syndrome is a condition where increased intra-abdominal pressure causes reduced blood flow to the abdominal organs and impaired diaphragm movement. It can cause respiratory distress, hypoxia, abdominal distension, acidosis, decreased urine output, and organ failure. It is a common complication of cirrhosis with ascites.

Choice D reason: Sepsis is a condition where a systemic inflammatory response to an infection causes organ dysfunction and hypoperfusion. It can cause respiratory distress, hypoxia, fever or hypothermia, tachycardia, acidosis, and hyperglycemia. However, it does not cause abdominal distension unless there is an intra-abdominal infection.

The two actions the nurse should take to address abdominal compartment syndrome are:

• Prepare the client for a paracentesis: Paracentesis is a procedure where a needle or catheter is inserted into the peritoneal cavity to drain excess fluid and reduce intra-abdominal pressure.
• Place an intravenous line to start fluid boluses: Fluid boluses are given to maintain adequate blood pressure and perfusion to the vital organs.

The two parameters the nurse should monitor to assess the client’s progress are:

• Oxygen saturation: Oxygen saturation reflects the amount of oxygen bound to hemoglobin in the blood. It should be maintained above 90% to ensure adequate oxygen delivery to the tissues.
• Urine output: Urine output reflects the function of the kidneys and the perfusion of the renal arteries. It should be maintained above 0.5 mL/kg/hour to prevent acute kidney injury and electrolyte imbalances.

Choice A reason: This is incorrect because monitoring pulse oximetry every 2 hours is not a sufficient or timely intervention for the nurse to implement. Pulse oximetry is a noninvasive method of measuring the oxygen saturation of hemoglobin in the blood. Normal oxygen saturation is 95% to 100%, while hypoxemia is less than 90%. However, pulse oximetry may not reflect the severity of respiratory distress or the effectiveness of nebulizer treatment in a client with asthma. Moreover, monitoring pulse oximetry every 2 hours is too infrequent for a client who is in acute respiratory distress and needs more frequent assessment and intervention.

Choice B reason: This is incorrect because teaching proper use of a rescue inhaler is not a priority or relevant intervention for the nurse to implement. A rescue inhaler is a type of short-acting bronchodilator that can be used to relieve acute asthma symptoms by relaxing the smooth muscles of the airways and improving airflow. However, teaching proper use of a rescue inhaler is not an urgent action for a client who is already receiving nebulizer treatment, which delivers a higher dose of medication directly to the lungs. Moreover, teaching proper use of a rescue inhaler is not appropriate for a client who is in respiratory distress and may not be able to focus or retain information.

Choice C reason: This is correct because elevating the head of bed to 90 degrees is the most important intervention for the nurse to implement. Elevating the head of bed to 90 degrees can help improve breathing and oxygenation by reducing pressure on the diaphragm and chest wall, increasing lung expansion and ventilation, and facilitating expectoration of mucus. This can enhance the effects of nebulizer treatment and reduce respiratory distress in a client with asthma.

Choice D reason: This is incorrect because determining exposure to asthmatic triggers is not an immediate or helpful intervention for the nurse to implement. Asthmatic triggers are substances or factors that can cause or worsen asthma symptoms by inducing inflammation or constriction of the airways. Examples of asthmatic triggers include allergens, irritants, infections, exercise, stress, or weather changes. However, determining exposure to asthmatic triggers is not a priority action for a client who is in respiratory distress and needs more urgent interventions to improve breathing and oxygenation. Moreover, determining exposure to asthmatic triggers may not change the management or outcome of an acute asthma attack that has already occurred.